Journal of Obstetrics and Gynaecology, 2014; 34: 248–250 © 2014 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2013.844113
OBSTETRICS
Body mass index and labour outcome in Egyptian women M. M. Shaban, Y. A. Bassiouny, I. M. Elzahaby & A. A. Hassan
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Department of Obstetrics and Gynaecology, Faculty of Medicine, Cairo University, Egypt
We conducted a cross-sectional descriptive study to evaluate the impact of body mass index (BMI) on maternal medical disorders, progress of labour, mode of delivery and neonatal outcome in Cairo University hospital between September 2012 and March 2013. A total of 574 parturients were divided into two groups: group A with a BMI ⬍ 30 and group B with a BMI ⱖ 30. A statistically significant difference was found in favour of group B, regarding medical disorders, especially gestational hypertension and preeclampsia (p ⬍ 0.001), caesarean deliveries (p ⬍ 0.001) and neonatal birth weight (p ⫽ 0.001). There was no difference regarding gestational age at delivery, progress of labour (cervical dilatation, cervical effacement, duration of first and second stage of labour) and neonatal outcome (Apgar score at 1 and 5 min and neonatal deaths). Our conclusion is that increased maternal BMI is associated with an increased incidence of medical disorders during pregnancy, caesarean section rate and fatal macrosomia. Keywords: Body mass index, labour outcome
Introduction Obesity is one of the most prevalent health problems worldwide. It is, in simple terms, excess deposition of fat in the body. It is usually assessed by the body mass index (BMI). A report by the World Health Organization (WHO) in 2005 declared that nearly 1.6 billion people were overweight and a minimum of 400 million were obese. A BMI of 20 to ⬍ 25 is considered normal; 25 to ⬍ 30 is overweight; 30 to ⬍ 35 is obese and ⬎ 35 is morbidly obese (WHO 2000). Women with an increased BMI have poor maternal and fetal outcomes in pregnancy. These include hypertensive disorders, gestational diabetes, pre- and post-term deliveries, induction of labour, instrumental deliveries, postpartum haemorrhage, wound infection and large-for-gestational-age babies (Villamor and Cnattinguis 2006). The Institute of Medicine of the National Academies in the USA in 1990, performed an analysis to estimate the average maternal weight gain in pregnancy in relation to the pre-pregnancy BMI. It concluded that a BMI of ⬍ 20 would allow a weight gain of 25–40 lb (12–18.5 kg); a BMI of 25 to ⬍ 30 can increase by 15– 25 lb (11.5–16 kg) and a BMI ⱖ 30 should only increase 15 lb (7–11.5 kg) to reduce the maternal and fetal adverse outcomes (National Research Council 1990). These results were revised in
2006, recommending further studies to determine the average increase in body weight that will optimise pregnancy outcome. Based on this, further studies have been conducted, and some agreed with the preliminary recommendations of the Institute of Medicine (Abrams et al. 2000; Krishnamoorthy et al. 2006; DeVader et al. 2007). Others however, advised a decrease in maternal weight gain during pregnancy (Cedergren 2007; Kiel et al. 2007). Different countries show different distributions of BMI, for example in some Asian countries such as Iran and Pakistan, women have a low BMI and a low increased weight gain during pregnancy compared with other developed countries (Yazdani et al. 2012), while in the USA, a BMI of ⬎ 25 is prevalent in ⬎ 50% of the women, which affects their pregnancy outcomes (Otal et al. 2011). There is therefore a need to determine the effect of BMI on the outcome of pregnancy among our population, and this was the aim of the present study.
Materials and methods This study was a descriptive cross-sectional study conducted in the Obstetric department in Cairo University Hospital, on 574 parturients. The women were divided into two groups: group A (control group) with a BMI of ⬍ 30 included 339 women and group B with a BMI of ⱖ 30 included 235 women. Approval of the ethical committee of the obstetrics and gynaecology department, Cairo University was taken before conducting our study. Inclusion criteria were: active labour, all primigravidas, housewives, aged 17–36 years, full-term singleton pregnancy, cephalic presentation and no fetal congenital anomalies. Women who were excluded from the study were those with multiple pregnancies, abnormal presentation and position or previous surgical history on the uterus. Upon admission, and once the inclusion criteria were fulfilled, an informed consent was taken from the women to participate in our study. A full history and examination, including blood pressure, weight and height with calculation of the BMI (weight in kg)/(height in m2), vaginal examination (cervical dilatation, effacement, presentation, position, condition of membranes and station of fetal head) were done. Routine laboratory work-up was done in the form of their Rh group, complete blood picture, random blood sugar level and urine analysis. Assessment of the progress of labour, fetal condition and calculation of the duration of the first stage was done using a
Correspondence: M. M. Shaban, Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Manial, Cairo, Egypt. E-mail: drmonashaban@ gmail.com
BMI and labor outcome 249
J Obstet Gynaecol Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 04/03/15 For personal use only.
partogram. Researchers attended or conducted the deliveries to determine the duration of the second stage, mode of delivery (whether caesarean section (CS) or normal vaginal delivery, NVD), the fetal outcome, neonatal body weight and the Apgar score at 1 and 5 minutes. Data were statistically analysed in terms of mean ⫾ standard deviation (SD), and range, or frequencies (number of cases) and percentages when appropriate. Comparison of numerical variables between the study groups was done using the Student’s t-test for independent samples. For contrasting categorical data, a χ2-test was performed. Exact test was performed instead when the expected frequency was ⬍ 5. A p value ⬍ 0.05 was considered statistically significant. All statistical equations were done using computer programs SPSS (Statistical Package for the Social Science; SPSS Inc., Chicago, IL) version 15 for Windows.
Results Our study included 574 parturients, who were divided into two groups: group A (339 parturients) with a BMI of ⬍ 30 and group B (235 parturients) with a BMI of ⱖ 30. There was a significant difference between the two groups in age and BMI, both being higher in group B (Table I). There was a statistically significant difference between the two groups in the number of parturients having medical disorders (p ⬍ 0.001). In group A, 64 parturients complained of a medical problem (18.9%) and in group B, 81 participants had a medical problem (34.5%) (Table II). The most frequent medical problem encountered in both groups was hypertension, including gestational hypertension and pre-eclampsia. There was no statistically significance difference between both groups regarding gestational age at delivery. In group A, the mean gestational age at delivery was 273 ⫾ 13 days, while in group B, it was 272 ⫾ 14 days (p ⫽ 0.224). Regarding spontaneous rupture of membranes (ROM) there was no difference statistically between both groups: 157 parturients (46.3%) in group A and 107 parturients (45.5%) in group B (p ⫽ 0.854). There was a statistically significant difference between the groups regarding mode of delivery: 58 women in group A delivered by CS (17.1%) and 76 women (32.3%) in group B delivered by CS (p ⬍ 0.001). Regarding women who delivered vaginally in both groups, in group A 281 women delivered vaginally (82.9%) and in group B, 159 women delivered vaginally (67.7%). Both groups were comparable regarding cervical dilatation, cervical effacement and duration of the first and second stages of labour (Table III). When we analysed the fetal outcomes, there was a significant difference in the neonatal birth weight (NBW) between the two groups. In group A, the mean NBW was 2.97 ⫾ 0.41 kg and in group B, it was 3.09 ⫾ 0.45 kg, thus being higher in group B (p ⫽ 0.001). There was no difference in Apgar scores at 1 and 5 minutes between the two groups. Apgar at 1 minute in the two groups was 7.18 ⫾ 0.74 minutes and 7.16 ⫾ 0.76 minutes,
Table II. Medical disorders which were encountered in both groups. Group A (BMI ⬍ 30)
Group B (BMI ⱖ 30)
n
(%)
n
(%)
1 1 1 1 1 1 48 0 1 9 0 275 339
0.3 0.3 0.3 0.3 0.3 0.3 14.2 0.0 0.3 2.7 0.0 81.1 100
1 0 1 0 0 0 75 1 0 2 1 154 235
0.4 0.0 0.4 0.0 0.0 0.0 31.9 0.4 0.0 0.9 0.4 65.5 100
Medical trouble Anaemia Atrial septal defect repair Cardiac Diabetes mellitus Epilepsy Fever Hypertension (HTN) HTN and rheumatic heart disease Marfan syndrome, aortic regurgitation RHD Ventricular septal defect (VSD) NAD (no abnormality detected) Total
respectively (p ⫽ 0.834). Apgar at 5 minutes in the two groups was 9.60 ⫾ 0.65 minutes and 9.61 ⫾ 0.78 minutes, respectively (p ⫽ 0.862). There were two neonatal deaths in group A (0.6%) and none in group B; this did not represent a significant difference; p value was 0.516. Regarding the fetal gender, 173 (51%) of the women in group A gave birth to males and 129 (54.9%) women in group B gave birth to males (p ⫽ 0.362).
Discussion Obesity has a great impact on pregnancy, with an increase in the incidence of maternal and fetal complications. This is also reflected on the cost of antenatal, intrapartum and postpartum care (Leonie et al. 2006). In this study, we studied the effect of BMI on medical disorders encountered, gestational age at delivery, progress and duration of labour (both first and second stages), mode of delivery (whether CS or NVD) and the effect on the newborn (birth weight and Apgar scores at 1 and 5 minutes). A total of 574 women were divided according to their BMI into two groups: group A, with a BMI of ⬍ 30 (included 339 women) and group B, with a BMI ⱖ 30 (included 235 women). Treatment allocation was the same in both groups for induction by oxytocin and treatment of different medical disorders associated with pregnancy. There were more medical disorders in group B, especially hypertension (gestational hypertension and pre-eclampsia); this was attributed to the increased BMI. This agrees with several studies, for example Weiss et al. (2004) composed a prospective multicentre study including 16,102 women who showed a significant increase in medical disorders in morbid obese women including hypertension, pre-eclampsia and diabetes. El Chaar et al. (2013) and Rode et al. (2005) showed a similar increase in medical disorders, especially in morbidly obese parturients.
Table I. Shows distribution, maternal age and BMI in both groups.
Group A (BMI ⬍ 30) Group B (BMI ⱖ 30) p value
Mean maternal age (years)
Mean BMI (kg/m2)
21.6 ⫾ 3.3 22.6 ⫾ 3.9 ⬍ 0.001∗
26.3 ⫾ 2.4 35.2 ⫾ 4.9 ⬍ 0.001∗
∗p ⬍ 0.05 is considered statistically significant.
Table III. Comparing the progress of labour in both groups.
Cervical dilatation (cm) Cervical effacement (%) 1st stage duration (h) 2nd stage duration (min)
Group A
Group B
p value
5.2 ⫾ 2.1 74.1 ⫾ 16.8 9.4 ⫾ 4.2 27.8 ⫾ 14.2
5.1 ⫾ 1.9 70.8 ⫾ 18.7 8.8 ⫾ 3.9 29.2 ⫾ 14.8
0.426 0.06 0.167 0.338
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In our study, there was no difference in the gestational age at time of delivery between both groups, which is in agreement with Stepan et al. (2006), who conducted a similar study in 5,067 women, retrospectively, showing no effect of BMI on the gestation at delivery. Contrary to this, however, several studies reported post-datism with a BMI ⬎ 30 (Johnson et al. 1992; Denison et al. 2008), while other studies reported an increase in preterm deliveries with an elevated BMI (Raja et al. 2012). There was no difference between both groups regarding the progress of labour which is contrary to some other studies which showed an increase in the duration of labour in cases of increased BMI (Vahvatian et al. 2004; Norman et al. 2012). Our study supports previous studies which showed an increased incidence of caesarean section with maternal BMI (Johnson et al. 1992; Weiss et al. 2004; Rode et al. 2005; Denison et al. 2008; Ovesen et al. 2011; Raja et al. 2012; El Chaar et al. 2013). There were 58 women who delivered by CS in group A (17.1%) and 76 women (32.3%) who delivered by CS in group B. The increased incidence of CS among obese women may be attributed to increase in soft tissue in the maternal pelvis and fetal macrosomia in cases of obesity. Whiteman and colleagues (2011) studied the effect of BMI change during pregnancy and concluded that an increase in BMI during pregnancy from normal to obese, or maintaining the obese state, increased the risk of caesarean delivery, while a reduction of BMI from obese to normal during pregnancy reduced the risk of caesarean delivery to that of a normal BMI woman. Regarding the neonatal outcome, the weight of newborns for group B was significantly higher than in group A (p ⫽ 0.001). This was similar to many studies which showed macrosomia or largefor-gestational-age fetuses with increasing BMI (Johnson et al. 1992; Weiss et al. 2004; Raja et al. 2012). Apgar scores at 1 minute and at 5 minutes in both groups did not show a statistically significant difference. These results are comparable with the results of Rode et al. (2005). However, some studies showed a reduction in the Apgar score at 1 minute (El-Gilany and Hammad 2010; Ovesen et al. 2011; Raja et al. 2012), and others assessed the Apgar score at 5 minutes also with low values in obese women (Chen et al. 2010; Raja et al. 2012). Based on these observations, an effort should be made to restore an adequate BMI before pregnancy and proper antenatal care is required to assure proper weight gain and prevent excessive weight gain, which is attributed to more maternal complications and a higher incidence of caesarean delivery. The limitation of the current study is the lack of knowledge of the pre-pregnancy weight and thus the BMI of the pregnant women, so we depended on the BMI at the time of delivery. One of the strengths of the current study is that it was done in the same centre, with application of the same protocols and indications for caesarean delivery for all the women enrolled in the study.
Acknowledgement Our thanks go to all parturients who participated in our study and to all medical staff in the Cairo University Hospital, Obstetrics department, for their cooperation and help. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Abrams B, Altman SL, Pickett KE. 2000. Pregnancy weight gain: still controversial. American Journal of Clinical Nutrition 71:1233–1241. Cedergren MI. 2007. Optimal gestational weight gain for body mass index categories. Obstetrics and Gynecology 110:759–764. Chen M, McNiff C, Madan J, Goodman E, Davis JM, Dammann O. 2010. Maternal obesity and neonatal Apgar scores. Journal of Maternal-Fetal and Neonatal Medicine 23:89–95. Denison FC, Price J, Graham C, Wild S, Liston WA. 2008. Maternal obesity, length of gestation, risk of postdates pregnancy and spontaneous onset of labour at term. British Journal of Obstetrics and Gynaecology 115:720–725. DeVader SR, Neeley HL, Myles TD, Leet TL. 2007. Evaluation of gestational weight gain guidelines for women with normal prepregnancy body mass index. Obstetrics and Gynecology 110:745–751. El Chaar D, Finkelstein SA, Tu X, Fell DB, Gaudet L, Sylvain J et al. 2013. The impact of increasing obesity class on obstetrical outcomes. Journal of Obstetrics and Gynaecology Canada 35:224–233. El-Gilany AH, Hammad S. 2010. Body mass index and obstetric outcomes in pregnant in Saudi Arabia: a prospective cohort study. Annals of Saudi Medicine 30:376–380. Johnson JW, Longnate JA, Frentzen B. 1992. Excessive maternal weight and pregnancy outcome. American Journal of Obstetrics and Gynecology 167:353–370. Kiel DW, Dodson EA, Rartal TK, Boehmery Leet TL. 2007. Gestational weight gain and pregnancy outcomes in obese women: how much is enough? Obstetrics and Gynecology 110:752–758. Krishnamoorthy U, Schram CM, Hill SR. 2006. Maternal obesity in pregnancy: is it time for meaningful research to inform preventive and management strategies? British Journal of Obstetrics and Gynaecology 113:1134–1140. Leonie K, Callaway K, Jehannes B, Allan M, David McIntyre H. 2006. The prevalence and impact of overweight and obesity in an Australian obstetric population. Medical Journal of Australia184:56–59. National Research Council. 1990. Nutrition during pregnancy: Part I: Weight gain, Part II: Nutrient supplements. Washington, DC: The National Academies Press. p. 27–33. Norman SM, Tuuli MG, Odibo AO, Caughey AB, Roehl KA, Cahill AG. 2012. The effects of obesity on the first stage of labour. Obstetrics and Gynecology 120:130–135. Otal E, Haruma M, Suzuli M, DucAnh D, Tho LH, Thanh Tam NT et al. 2011. Maternal Body Mass index and gestational weight gain and their association with perinatal outcomes in Vietnam. Bulletin of the World Health Organization 89:127–136. Ovesen P, Rasmussen S, Kesmodel U. 2011. Effect of prepregnancy maternal overweight and obesity on pregnancy outcome. Obstetrics and Gynecology 1118:305–312. Raja UA, Mcaree T, Bassett P, Sharma S. 2012. The implications of a raised maternal BMI: a DGH experience. Journal of Obstetrics and Gynaecology 32:247–251. Rode L, Nilas L, Wøjdemann K, Tabor A. 2005. Obesity-related complications in Danish single cephalic term pregnancies. Obstetrics and Gynecology 105:537–542. Stepan H, Scheithauer S, Dornhöfer N, Krämer T, Faber R. 2006. Obesity as an obstetric risk factor: does it matter in a perinatal center? Obesity 14:770–773. Vahvatian A, Zhang J, Troendle JF, Savitz DA, Siega-Riz AM. 2004. Maternal prepregnancy overweight and obesity and the pattern of labour progression in term nulliparous women. Obstetrics and Gynecology 104:943–951. Villamor E, Cnattinguis S. 2006. Interpregnancy weight change and risk of adverse pregnancy outcomes: a population-based study. Lancet 368:1164–1170. Weiss JL, Malone FD, Emig D, Ball RH, Nyberg DA, Comstask CH: FASTER Research Consortium. 2004. Obstetric complications and cesarean delivery rate: a population based screening study. American Journal of Obstetrics and Gynecology 190:1091–1097. Whiteman VE, McIntosh C, Rao K, Mbah AK, Salihu HM. 2011. Interpregnancy BMI change and risk of primary caesarean delivery. Journal of Obstetrics and Gynaecology 31:589–593. WHO. 2000. Obesity: preventing and managing the global epidemic. WHO Technical Report Series 894. Geneva: World Health Organization. Yazdani S, Yosofniyapasha Y, Nasab BH, Mojaveri MH, Bowzari Z. 2012. Effect of maternal body mass index on pregnancy outcome and newborn weight. BMC Research Notes 5:34.
OBSTETRICS
Body mass index and labour outcome in Egyptian women M. M. Shaban, Y. A. Bassiouny, I. M. Elzahaby & A. A. Hassan
J Obstet Gynaecol Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 04/03/15 For personal use only.
Department of Obstetrics and Gynaecology, Faculty of Medicine, Cairo University, Egypt
We conducted a cross-sectional descriptive study to evaluate the impact of body mass index (BMI) on maternal medical disorders, progress of labour, mode of delivery and neonatal outcome in Cairo University hospital between September 2012 and March 2013. A total of 574 parturients were divided into two groups: group A with a BMI ⬍ 30 and group B with a BMI ⱖ 30. A statistically significant difference was found in favour of group B, regarding medical disorders, especially gestational hypertension and preeclampsia (p ⬍ 0.001), caesarean deliveries (p ⬍ 0.001) and neonatal birth weight (p ⫽ 0.001). There was no difference regarding gestational age at delivery, progress of labour (cervical dilatation, cervical effacement, duration of first and second stage of labour) and neonatal outcome (Apgar score at 1 and 5 min and neonatal deaths). Our conclusion is that increased maternal BMI is associated with an increased incidence of medical disorders during pregnancy, caesarean section rate and fatal macrosomia. Keywords: Body mass index, labour outcome
Introduction Obesity is one of the most prevalent health problems worldwide. It is, in simple terms, excess deposition of fat in the body. It is usually assessed by the body mass index (BMI). A report by the World Health Organization (WHO) in 2005 declared that nearly 1.6 billion people were overweight and a minimum of 400 million were obese. A BMI of 20 to ⬍ 25 is considered normal; 25 to ⬍ 30 is overweight; 30 to ⬍ 35 is obese and ⬎ 35 is morbidly obese (WHO 2000). Women with an increased BMI have poor maternal and fetal outcomes in pregnancy. These include hypertensive disorders, gestational diabetes, pre- and post-term deliveries, induction of labour, instrumental deliveries, postpartum haemorrhage, wound infection and large-for-gestational-age babies (Villamor and Cnattinguis 2006). The Institute of Medicine of the National Academies in the USA in 1990, performed an analysis to estimate the average maternal weight gain in pregnancy in relation to the pre-pregnancy BMI. It concluded that a BMI of ⬍ 20 would allow a weight gain of 25–40 lb (12–18.5 kg); a BMI of 25 to ⬍ 30 can increase by 15– 25 lb (11.5–16 kg) and a BMI ⱖ 30 should only increase 15 lb (7–11.5 kg) to reduce the maternal and fetal adverse outcomes (National Research Council 1990). These results were revised in
2006, recommending further studies to determine the average increase in body weight that will optimise pregnancy outcome. Based on this, further studies have been conducted, and some agreed with the preliminary recommendations of the Institute of Medicine (Abrams et al. 2000; Krishnamoorthy et al. 2006; DeVader et al. 2007). Others however, advised a decrease in maternal weight gain during pregnancy (Cedergren 2007; Kiel et al. 2007). Different countries show different distributions of BMI, for example in some Asian countries such as Iran and Pakistan, women have a low BMI and a low increased weight gain during pregnancy compared with other developed countries (Yazdani et al. 2012), while in the USA, a BMI of ⬎ 25 is prevalent in ⬎ 50% of the women, which affects their pregnancy outcomes (Otal et al. 2011). There is therefore a need to determine the effect of BMI on the outcome of pregnancy among our population, and this was the aim of the present study.
Materials and methods This study was a descriptive cross-sectional study conducted in the Obstetric department in Cairo University Hospital, on 574 parturients. The women were divided into two groups: group A (control group) with a BMI of ⬍ 30 included 339 women and group B with a BMI of ⱖ 30 included 235 women. Approval of the ethical committee of the obstetrics and gynaecology department, Cairo University was taken before conducting our study. Inclusion criteria were: active labour, all primigravidas, housewives, aged 17–36 years, full-term singleton pregnancy, cephalic presentation and no fetal congenital anomalies. Women who were excluded from the study were those with multiple pregnancies, abnormal presentation and position or previous surgical history on the uterus. Upon admission, and once the inclusion criteria were fulfilled, an informed consent was taken from the women to participate in our study. A full history and examination, including blood pressure, weight and height with calculation of the BMI (weight in kg)/(height in m2), vaginal examination (cervical dilatation, effacement, presentation, position, condition of membranes and station of fetal head) were done. Routine laboratory work-up was done in the form of their Rh group, complete blood picture, random blood sugar level and urine analysis. Assessment of the progress of labour, fetal condition and calculation of the duration of the first stage was done using a
Correspondence: M. M. Shaban, Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Manial, Cairo, Egypt. E-mail: drmonashaban@ gmail.com
BMI and labor outcome 249
J Obstet Gynaecol Downloaded from informahealthcare.com by University of Ulster at Jordanstown on 04/03/15 For personal use only.
partogram. Researchers attended or conducted the deliveries to determine the duration of the second stage, mode of delivery (whether caesarean section (CS) or normal vaginal delivery, NVD), the fetal outcome, neonatal body weight and the Apgar score at 1 and 5 minutes. Data were statistically analysed in terms of mean ⫾ standard deviation (SD), and range, or frequencies (number of cases) and percentages when appropriate. Comparison of numerical variables between the study groups was done using the Student’s t-test for independent samples. For contrasting categorical data, a χ2-test was performed. Exact test was performed instead when the expected frequency was ⬍ 5. A p value ⬍ 0.05 was considered statistically significant. All statistical equations were done using computer programs SPSS (Statistical Package for the Social Science; SPSS Inc., Chicago, IL) version 15 for Windows.
Results Our study included 574 parturients, who were divided into two groups: group A (339 parturients) with a BMI of ⬍ 30 and group B (235 parturients) with a BMI of ⱖ 30. There was a significant difference between the two groups in age and BMI, both being higher in group B (Table I). There was a statistically significant difference between the two groups in the number of parturients having medical disorders (p ⬍ 0.001). In group A, 64 parturients complained of a medical problem (18.9%) and in group B, 81 participants had a medical problem (34.5%) (Table II). The most frequent medical problem encountered in both groups was hypertension, including gestational hypertension and pre-eclampsia. There was no statistically significance difference between both groups regarding gestational age at delivery. In group A, the mean gestational age at delivery was 273 ⫾ 13 days, while in group B, it was 272 ⫾ 14 days (p ⫽ 0.224). Regarding spontaneous rupture of membranes (ROM) there was no difference statistically between both groups: 157 parturients (46.3%) in group A and 107 parturients (45.5%) in group B (p ⫽ 0.854). There was a statistically significant difference between the groups regarding mode of delivery: 58 women in group A delivered by CS (17.1%) and 76 women (32.3%) in group B delivered by CS (p ⬍ 0.001). Regarding women who delivered vaginally in both groups, in group A 281 women delivered vaginally (82.9%) and in group B, 159 women delivered vaginally (67.7%). Both groups were comparable regarding cervical dilatation, cervical effacement and duration of the first and second stages of labour (Table III). When we analysed the fetal outcomes, there was a significant difference in the neonatal birth weight (NBW) between the two groups. In group A, the mean NBW was 2.97 ⫾ 0.41 kg and in group B, it was 3.09 ⫾ 0.45 kg, thus being higher in group B (p ⫽ 0.001). There was no difference in Apgar scores at 1 and 5 minutes between the two groups. Apgar at 1 minute in the two groups was 7.18 ⫾ 0.74 minutes and 7.16 ⫾ 0.76 minutes,
Table II. Medical disorders which were encountered in both groups. Group A (BMI ⬍ 30)
Group B (BMI ⱖ 30)
n
(%)
n
(%)
1 1 1 1 1 1 48 0 1 9 0 275 339
0.3 0.3 0.3 0.3 0.3 0.3 14.2 0.0 0.3 2.7 0.0 81.1 100
1 0 1 0 0 0 75 1 0 2 1 154 235
0.4 0.0 0.4 0.0 0.0 0.0 31.9 0.4 0.0 0.9 0.4 65.5 100
Medical trouble Anaemia Atrial septal defect repair Cardiac Diabetes mellitus Epilepsy Fever Hypertension (HTN) HTN and rheumatic heart disease Marfan syndrome, aortic regurgitation RHD Ventricular septal defect (VSD) NAD (no abnormality detected) Total
respectively (p ⫽ 0.834). Apgar at 5 minutes in the two groups was 9.60 ⫾ 0.65 minutes and 9.61 ⫾ 0.78 minutes, respectively (p ⫽ 0.862). There were two neonatal deaths in group A (0.6%) and none in group B; this did not represent a significant difference; p value was 0.516. Regarding the fetal gender, 173 (51%) of the women in group A gave birth to males and 129 (54.9%) women in group B gave birth to males (p ⫽ 0.362).
Discussion Obesity has a great impact on pregnancy, with an increase in the incidence of maternal and fetal complications. This is also reflected on the cost of antenatal, intrapartum and postpartum care (Leonie et al. 2006). In this study, we studied the effect of BMI on medical disorders encountered, gestational age at delivery, progress and duration of labour (both first and second stages), mode of delivery (whether CS or NVD) and the effect on the newborn (birth weight and Apgar scores at 1 and 5 minutes). A total of 574 women were divided according to their BMI into two groups: group A, with a BMI of ⬍ 30 (included 339 women) and group B, with a BMI ⱖ 30 (included 235 women). Treatment allocation was the same in both groups for induction by oxytocin and treatment of different medical disorders associated with pregnancy. There were more medical disorders in group B, especially hypertension (gestational hypertension and pre-eclampsia); this was attributed to the increased BMI. This agrees with several studies, for example Weiss et al. (2004) composed a prospective multicentre study including 16,102 women who showed a significant increase in medical disorders in morbid obese women including hypertension, pre-eclampsia and diabetes. El Chaar et al. (2013) and Rode et al. (2005) showed a similar increase in medical disorders, especially in morbidly obese parturients.
Table I. Shows distribution, maternal age and BMI in both groups.
Group A (BMI ⬍ 30) Group B (BMI ⱖ 30) p value
Mean maternal age (years)
Mean BMI (kg/m2)
21.6 ⫾ 3.3 22.6 ⫾ 3.9 ⬍ 0.001∗
26.3 ⫾ 2.4 35.2 ⫾ 4.9 ⬍ 0.001∗
∗p ⬍ 0.05 is considered statistically significant.
Table III. Comparing the progress of labour in both groups.
Cervical dilatation (cm) Cervical effacement (%) 1st stage duration (h) 2nd stage duration (min)
Group A
Group B
p value
5.2 ⫾ 2.1 74.1 ⫾ 16.8 9.4 ⫾ 4.2 27.8 ⫾ 14.2
5.1 ⫾ 1.9 70.8 ⫾ 18.7 8.8 ⫾ 3.9 29.2 ⫾ 14.8
0.426 0.06 0.167 0.338
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In our study, there was no difference in the gestational age at time of delivery between both groups, which is in agreement with Stepan et al. (2006), who conducted a similar study in 5,067 women, retrospectively, showing no effect of BMI on the gestation at delivery. Contrary to this, however, several studies reported post-datism with a BMI ⬎ 30 (Johnson et al. 1992; Denison et al. 2008), while other studies reported an increase in preterm deliveries with an elevated BMI (Raja et al. 2012). There was no difference between both groups regarding the progress of labour which is contrary to some other studies which showed an increase in the duration of labour in cases of increased BMI (Vahvatian et al. 2004; Norman et al. 2012). Our study supports previous studies which showed an increased incidence of caesarean section with maternal BMI (Johnson et al. 1992; Weiss et al. 2004; Rode et al. 2005; Denison et al. 2008; Ovesen et al. 2011; Raja et al. 2012; El Chaar et al. 2013). There were 58 women who delivered by CS in group A (17.1%) and 76 women (32.3%) who delivered by CS in group B. The increased incidence of CS among obese women may be attributed to increase in soft tissue in the maternal pelvis and fetal macrosomia in cases of obesity. Whiteman and colleagues (2011) studied the effect of BMI change during pregnancy and concluded that an increase in BMI during pregnancy from normal to obese, or maintaining the obese state, increased the risk of caesarean delivery, while a reduction of BMI from obese to normal during pregnancy reduced the risk of caesarean delivery to that of a normal BMI woman. Regarding the neonatal outcome, the weight of newborns for group B was significantly higher than in group A (p ⫽ 0.001). This was similar to many studies which showed macrosomia or largefor-gestational-age fetuses with increasing BMI (Johnson et al. 1992; Weiss et al. 2004; Raja et al. 2012). Apgar scores at 1 minute and at 5 minutes in both groups did not show a statistically significant difference. These results are comparable with the results of Rode et al. (2005). However, some studies showed a reduction in the Apgar score at 1 minute (El-Gilany and Hammad 2010; Ovesen et al. 2011; Raja et al. 2012), and others assessed the Apgar score at 5 minutes also with low values in obese women (Chen et al. 2010; Raja et al. 2012). Based on these observations, an effort should be made to restore an adequate BMI before pregnancy and proper antenatal care is required to assure proper weight gain and prevent excessive weight gain, which is attributed to more maternal complications and a higher incidence of caesarean delivery. The limitation of the current study is the lack of knowledge of the pre-pregnancy weight and thus the BMI of the pregnant women, so we depended on the BMI at the time of delivery. One of the strengths of the current study is that it was done in the same centre, with application of the same protocols and indications for caesarean delivery for all the women enrolled in the study.
Acknowledgement Our thanks go to all parturients who participated in our study and to all medical staff in the Cairo University Hospital, Obstetrics department, for their cooperation and help. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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